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Ann Thorac Surg 2002;74:1631-1634
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Intermediate term follow-up of the end-to-side aortic anastomosis for coarctation of the aorta

Adel K. Younoszai, MD*a, Vadiyala Mohan Reddy, MDa, Frank L. Hanley, MDa, Michael M. Brook, MDa

a Divisions of Pediatric Cardiology and Pediatric Cardiothoracic Surgery, University of California San Francisco, San Francisco, California, USA

Accepted for publication June 12, 2002.

* Address reprint requests to Dr Younoszai, The Center for Pediatric and Congenital Heart Diseases, The Cleveland Clinic Foundation/M41, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
e-mail: younosa{at}ccf.org


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKROUND: Classic techniques for repairing coarctation of the aorta, especially in neonates, have a significant incidence of recurrent obstruction. By connecting the descending aorta to the proximal aortic arch, the end-to-side aortic anastomosis isolates hypoplastic distal arch and encroaching ductal tissue from the anastomotic site.

METHODS: Follow-up data were available for 88 patients (54 male) who underwent an end-to-side aortic anastomosis from November 1992 until November 1999. The median postoperative follow-up was 1.9 years (range, 0.1 to 6.3 years). Fifty-four patients were corrected as neonates. Thirty-four patients were operated on out of the neonatal period (> 1 month of age). A systolic blood pressure gradient >= 20 mm Hg and a Doppler flow velocity >= 2.5 ms across the area of repair were considered a recurrent obstruction.

RESULTS: No patients in the pediatric group had a recurrent obstruction. In the neonatal group, 3 patients (5.5%) had recurrent obstruction. Of those, 2 patients had a reintervention performed; one reintervention was a balloon angioplasty and the other one was a reoperation. Kaplan-Meier analysis of the neonatal group revealed a 95.8% freedom from reintervention at 1 and 2 years.

CONCLUSIONS: The end-to-side aortic anastomosis is an effective repair for coarctation of the aorta. Even when performed in the neonatal period, recurrence of coarctation is rare.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Coarctation of the aorta accounts for 5% to 10% of all congenital heart lesions and for 7% to 10% of critically ill infants with heart disease [1]. The simple definition of coarctation of the aorta is a narrowing of the proximal descending aorta, commonly occurring just distal to the origin of the left subclavian artery. However it is a more complex disease than this definition suggests. Coarctation is often associated with other cardiac lesions such as bicuspid aortic valve, with or without stenosis, and ventricular septal defect. In addition, the aortic arch especially in the neonatal patient is often hypoplastic, and abnormal contractile tissue from the ductus arteriosus may encroach onto the aorta proximally to the isthmus.

Many surgical techniques to fix a coarctation of the aorta incorporate abnormal tissue in the final repair with a risk of recurrent obstruction requiring intervention. It was observed that patients with interruption of the aortic arch who underwent an end-to-side type of anastomosis had a very low rate of recurrent obstruction. It was hypothesized that the absence of hypoplastic distal arch and peri-ductal tissue might be the reason for the lower recurrence rate.

This approach has been adopted for coarctation repair in a small number of centers over the last 10 years [2]. By connecting the descending aorta to the proximal aortic arch, the end-to-side aortic anastomosis eliminates the isthmus and hypoplastic distal arch tissue from the anastomotic site. We reviewed the perioperative course and follow-up data for pediatric and neonatal patients that underwent an end-to-side aortic anastomosis from November 1992 to November 1999.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
End-to-side aortic anastomosis
The end-to-side aortic anastomosis procedure was performed as described (Fig 1).



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  		Fig 1. End-to-side aortic anastomosis for coarctation of the aorta as seen through the left lateral posterior thoracotomy. (A) Basic anatomy. (A = artery; AAo = ascending aorta; DA = ductus arteriosus; DAo = descending aorta [dashed lines indicate lines of incision]). (B) Surgical procedure. Cross clamps are placed across the proximal descending aorta and proximal arch to include the left head and neck vessels. The ductus arteriosus is ligated and excised with the coarctation, and the distal aortic arch is tied off. (C) Resulting repair. The descending aorta has been pulled up to the undersurface of the proximal arch and anastomosed in an end-to-side fashion. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 1996, 61, 840–4] [2].)

 
Patient selection
An end-to-side aortic anastomosis was performed on 95 children from November 1992 to November 1999. Follow-up data were collected on 88 patients (54 male). Because of the more complicated nature of the repair in the newborn period, the patients were divided into a pediatric group (n = 34) defined as more than 1 month of age, and a neonatal group <= 1 month of age (n = 54). A 2-month old infant who presented in extremis with a diffusely hypoplastic arch requiring a prostaglandin infusion for resuscitation was included in the neonatal group.

Data collection
Perioperative and postoperative mortality was noted from our surgical database. The inpatient chart, outpatient clinical notes, and echocardiographic were reviewed. Perioperative data included weight at operation, cross-clamp time, worst preoperative and postoperative blood pressure gradients between the right arm and either leg, and duration of postoperative hospital stay.

Follow-up variables included blood pressure gradient between the right arm and a lower extremity and Doppler velocity across the proximal descending aorta. A recurrent obstruction was considered to have occurred if both the blood pressure gradient between the right arm and a leg was >= 20 mm Hg and if the flow velocity in the proximal descending aorta was >= 2.5 ms as estimated by Doppler echocardiography. In some cases, patients with no blood pressure gradient and a normal physical examination did not have an echocardiogram performed.

In the pediatric group, clinical follow-up was available at a median of 2.2 postoperative years (range, 0.4 to 6.3 years). In the neonatal group, clinical follow-up was available at a median of 1.7 postoperative years (range, 0.1 to 6.3 years).

The study protocol was approved by our institutional internal review board.

Statistics
Standard descriptive analyses were performed on the demographic data. Freedom from intervention after repair was assessed using standard Kaplan-Meyer analysis.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Mortality
There were no perioperative or early deaths. There were 4 late patient deaths from hemodynamic collapse for a total mortality of 4.2%. All 4 patients had complex cardiac lesions; 2 patients had Shone syndrome with a borderline left ventricle, 1 patient had d-transposition of the great arteries with a ventricular septal defect, and 1 patient had dextrocardia with multiple ventricular septal defects. None of the patients had a recurrent arch obstruction.

Morbidity
In our cohort, 6 patients had postoperative complications requiring intervention. One patient had a left diaphrag-matic palsy that required plication. Another had a chylothorax with subsequent ligation of the thoracic duct. Four other patients had minor wound infections that were treated with a course of intravenous antibiotics and resolved. There were no neurologic complications.

Perioperative data
Perioperative data are shown in Table 1.


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  		Table 1. Perioperative Demographic Dataa

 
Other cardiac anomalies
A ventricular septal defect was present in 15 patients (16%). Of the 11 neonatal patients with coarctation and a ventricular septal defect, 3 had a pulmonary artery band placed concurrently, 3 had a subsequent repair 1 month to 5 years later, and 2 had spontaneous closure of the ventricular septal defect; the other 3 patients had the ventricular septal defect closed and the coarctation repaired through a midline sternotomy. Including the 3 patients who had ventricular septal defect repairs, a total of 5 children underwent arch repair through a midline sternotomy. One patient had a concurrent Ross procedure and another had an unusual aneurysm of the aortic arch. None of the patients that had the end-to-side anastomosis preformed by sternotomy had a recurrence.

Other lesions encountered were an atrioventricular septal defect, mitral valve prolapse, and a right aortic arch.

Clinical follow-up
Pediatric group
No patient had a recurrent obstruction of the aortic arch. Although 2 children had elevated Doppler velocities, neither had a significant blood pressure gradient. Both of the patients with raised Doppler velocities had good pulses in their legs and normal blood pressure in their arms. No patient required reintervention.

Neonatal group
A recurrent obstruction by both blood pressure and echocardiography was documented in 3 infants (5.5%). Excluding patients who underwent repair through a midline sternotomy, the recurrence rate was 6.1%. There were 3 children who met one or two of the criteria: 1 child had an elevated blood pressure gradient with a normal echo and 2 children had normal blood pressure gradients with elevated Doppler velocities on each. None of these were believed to have a clinically significant coarctation by their cardiologists.

Of the 3 patients with recurrent obstruction, 2 underwent a repeat intervention. One patient underwent surgical patch augmentation of the distal aortic arch. The other patient had a 20 to 30 mm Hg gradient 1-month postoperatively noted during cardiac catheterization to address the patient’s valvar aortic stenosis; this patient underwent a repeat catheterization 1-month thereafter, and the gradient across the coarctation was 8 mm Hg, and simultaneously the aortic valve gradient was 20 mm Hg with a normal pressure tracing in the descending aorta. The decision was made to perform balloon angioplasty on this patient because of a high left ventricular end-diastolic pressure in the face of multiple obstructions.

The third patient was asymptomatic. Although this patient had a 20 mm Hg gradient by cuff pressure, normal pulses and no hypertension were found in the upper extremities. The patient also had aortic stenosis with high velocity flow into the ascending aorta, which made the velocity of flow across the proximal descending aorta difficult to interpret. By two-dimensional imaging, the aortic arch appeared normal.

By Kaplan-Meyer analysis, the freedom from reintervention for the neonatal group was 95.8% (standard error, 2.9%) at 1 year and 2 years (Fig 2). Both interventions occurred within the first 5 months after the end-to-side repair.



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  		Fig 2. Kaplan-Meier analysis of freedom from reintervention. The freedom from reintervention after 5 postoperative months is 94.7% (standard error, 3.7%). (Post-op = postoperatively.)

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
This study shows that by the intermediate term follow-up, the end-to-side aortic anastomosis is an effective repair for coarctation of the aorta. In our 88 pediatric and neonatal patients followed for a median of 1.8 years, the incidence of recurrent obstruction was low. Our pediatric patients had no recurrent obstruction. In the neonatal patients, which are traditionally more challenging, 3 patients had recurrent obstruction by our definition, but only 2 of them were felt to have a significant obstruction that required intervention. Thus, overall the re-coarctation rate was 3.8%, and the reintervention rate was only 2.3%.

A reason for the low reintervention rate may be that by tying off the isthmus and connecting the descending aorta to the proximal undersurface of the aortic arch, the end-to-side anastomosis avoids the incorporation of the distal arch in the repair. In addition, to deal with arch hypoplasia, the undersurface of the arch is opened with a lengthwise incision that enlarges the anastomosis to the descending aorta. Postoperatively, the aortic arch remodels, and imaging studies reveal normal appearing anatomy (Figs 3 and 4).



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  		Fig 3. Representative two-dimensional echocardiograms of the aortic arch visualized from the suprasternal notch. (A) Preoperatively there is narrowing of the isthmus and a tight juxtaductal coarctation (arrow). (B) After repair with the end-to-side aortic anastomosis, the aortic contour is smooth without narrowing. The arrow indicates the suture line of the anastomotic site.

 


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  		Fig 4. Representative cineangiograms of the aortic arch before and after the end-to-side aortic anastomosis. (A) Viewed from the left anterior oblique projection. Preoperatively the aortic arch is hypoplastic with a discrete posterior shelf (arrow) just distal to the take-off of the left subclavian artery. (B) Viewed from the lateral projection. Postoperatively the aortic arch has remodeled to form a normal contour.

 
Comparative techniques can be divided into the classic repairs including the traditional end-to-end aortic anastomosis, subclavian flap repair, and patch aortoplasty, and the newer techniques such as the extended end-to-end anastomosis and the modified subclavian flap repair. The classic repairs have traditionally had a high recurrence rate with most reporting an incidence of 10% to 20%, but as high as 41% [1, 3–14]. There are few reports with a large number of patients on the newer techniques; however, the early data seem to indicate a recurrence rate less than 10% [15–19]. For example, Backer and colleagues [20] in 1998 reviewed a series of 55 patients repaired with the extended end-to-end anastomosis and found recurrent obstruction in only 3.6%. However, all of these techniques include the distal aortic arch in the repair and therefore require the surgeon to identify and excise ductal tissue that can encroach onto the aorta. This tissue can be difficult to identify, especially in the neonatal patient on prostaglandin infusion with an open ductus arteriosus.

A problematic issue in evaluating coarctation repair effectiveness is defining a recurrent obstruction that requires intervention. A good physical examination that includes palpation of a pulse in the legs and blood pressures in the right arm and a leg remains the best screen. Echocardiography can lend additional information. The proximal descending aorta can be well visualized in most patients and increased Doppler flow velocity in that region may indicate a narrowing [21]. However, in the setting of accelerated flow in the ascending aorta caused by a bicuspid stenotic aortic valve, the velocity across the repair site may be meaningless. Even using the combination of extremity blood pressure and Doppler echocardiography, retrospectively, 1 patient who met our criteria was not believed to have a significant re-coarctation by his cardiologist.

In summary, this study shows a rate of recurrent obstruction necessitating reintervention in intermediate term follow-up that is significantly lower than classic surgical repairs and that compares favorably with the newer techniques. If the freedom from reintervention continues into long term follow-up, there will be a major decrease in the morbidity, mortality, and cost associated with recurrent intervention after surgical repair for aortic coarctation.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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